Thank you for your reply! I spent 17 years as a medical transcriptionist prior to obtaining my coding certification and I've worked in a medical field of some sort for the past 20 plus years. I feel I have a fairly good understanding of comorbid conditions. However, a couple of my providers (neurologists) recently had an official audit done and I received some feedback on my work as well. It was brought to my attention that I should not code comorbid conditions unless the physician specifically addresses them. With quite a few neurology patients following up for a recent stroke or a past history of a stroke/CVA/TIA, when the past medical history or HPI mentions hypertension or hyperlipidemia and/or the social history mentions the patient is a current smoker, yet the neurologist doesn't directly address these issues, I'm finding it hard to not code these conditions as I feel they do have an impact on the patient's care and the provider's MDM.
I also code for our wound clinic physicians and I'm running into comorbidities such as diabetes and smoking, but when the patient has a non-healing wound that isn't due to their diabetes, I'm supposed to leave the fact that they're a diabetic off the list of codes I use? With diabetes being a potential cause for a slow healing wound, I'm having trouble wrapping my head around why I shouldn't code it, as well as the negative effect smoking can have on diabetic wound healing, just because the physician doesn't directly address it, but does document that the patient has diabetes and is a smoker.
Any insight you have that may help me understand the thought process of leaving these issues out would be greatly appreciated. I like for things to make sense!